Atlas of Procedures in Neonatology, 4th Edition

Appendices

Appendix A: Chapter 5

TABLE A.1 Recommended Dosages and Oral/Parenteral Ratios for Opioids

 

TABLE A.2 Recommended Dosages for Nonsteroidal Anti-inflammatory Drugs

 

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Appendix B Chapter 31

TABLE B.1 Basic, All-Purpose Instrument Traya

 

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TABLE B.2 Selected Sutures Appropriate for Common Neonatal Procedures

 

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Appendix C: Chapter 41

TABLE C.1 Blood Products

 

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Appendix D: Chapter 34 Techniques for Endotracheal Intubation Specific to Unique Patient Needs

Elective Change of Orotracheal Tube in Intubated Patient

This procedure allows continued ventilation through a pre-established airway whenever it is necessary to change an endotracheal (ET) tube or to place a nasotracheal tube. By maintaining the original airway as long as possible during the change, there is less need for haste and less stress to the patient. An obvious prerequisite is that the original ET tube be patent and correctly positioned in the trachea.

Rapid Replacement Method

  1. Prepare equipment and patient as for initial orotracheal intubation.
  2. Release tube fixation device without displacing tube.
  3. Have assistant hold first ET tube in place at far left of the infant's mouth while continuing to ventilate infant.
  4. Visualize glottis with laryngoscope.
  5. Pass second orotracheal tube down far right of the mouth until it aligns with glottic opening.
  6. When new tube is positioned for direct insertion, have assistant withdraw first tube carefully.
  7. Advance new tube into position.
  8. Verify position and secure tube as previously described.

Alternative Method: Insertion over a Feeding Tube

Because of the narrow diameter of ET tubes in small infants, feeding tubes narrow enough to fit inside the ET lumen are often too flexible to stay within the trachea as the tubes are being changed. Be prepared to intubate directly should the feeding tube dislodge.

  1. Prepare equipment and patient as for initial orotracheal intubation.
  2. Release tube fixation device without displacing tube.
  3. Select the largest feeding tube that will easily go through the current and new endotracheal tubes. Remove the flared end of feeding tube and the adaptor on the new tube.
  4. Remove adaptor of currently in-place ET tube.
  5. Quickly insert the feeding tube through the lumen to a depth not greater than the ET tube.
  6. While holding feeding tube in place, pull ET tube out of trachea and off feeding tube.
  7. Slide new ET tube over feeding tube into trachea.
  8. Replace tube adaptor.
  9. Verify position and secure tube as previously described.

Selective Left Endobronchial Intubation

The angles of the bronchi are such that more often than not a tube will seek the right mainstem bronchus. The exceptions will be conditions that push the left side down (left upper-lobe emphysema) or that pull the right side up (marked upper-lobe atelectasis or hypoplasia). Normally, successful right mainstem intubation simply requires a longer tube. Selective intubation of the left bronchus is a more difficult and dangerous procedure; therefore, following all precautions is especially important.

Place the ET tube under guidance by direct bronchoscopy or under fluoroscopy when these procedures are available without compromise to infants (1,2).

The following procedure is a simple, indirect method based on a modification that tends to make the ET tube bend toward the left when it meets resistance at the carina (3).

  1. Cut an elliptical hole through half the diameter of ET tube 1 cm in length and 0.5 cm above the tip of the oblique distal end.
  2. Perform an orotracheal intubation as above, keeping the cut hole directed toward the left lung.
  3. Turn infant's head toward the right (4).
  4. While auscultating the lung fields, advance the tube to 0.5 to 1 cm below the calculated depth of the carina or until differential breath sounds are heard.
  5. If breath sounds diminish on the left, withdraw the ET tube until they return.
  6. Take a chest radiograph to confirm left bronchial position.
  7. Fix tube securely.
  8. Reassess position frequently, as tube may dislodge from one mainstem into the other.

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  1. Follow patient closely for particular complications of
  2. Air leak of ventilated area
  3. Stasis pneumonia of nonventilated area
  4. Dislodgement from left mainstem bronchus
  5. Ventilatory insufficiency due to significant disease in the only lung being ventilated

Nonvisualized Oral Intubation

This technique has a higher risk of complications and is less often successful than when direct visualization is used. Reserve the blind oral intubation for true emergencies in small infants when there is equipment failure (e.g., laryngoscope light) and when ventilation by mask is contraindicated (e.g., thick meconium).

  1. Stand at infant's feet.
  2. Carefully slide first two fingers of gloved, left hand into back of oropharynx at the base of tongue, until reaching vallecula and epiglottis. Keep fingers in the center of the tongue.
  3. Using index finger, pull epiglottis forward.
  4. Keep infant's head in midline.
  5. With right hand, guide ET tube, without stylet, along left middle finger, which is held just above index finger.
  6. Advance tube carefully just beyond fingertips.
  7. Avoid pushing against any obstruction.
  8. If available, have assistant press gently on trachea in suprasternal notch and report when tube passes under finger.
  9. Verify position, and fix tube as previously described.

Blind Nasotracheal Intubation (5)

Blind nasotracheal intubation is often used in adults. Because a stiff tube is needed, the chance of perforation in infants is greater if a stylet is used. Although an intubation under direct visualization is preferred, the presence of severe microagnathia or oral masses makes this approach valuable. It is critical not to push against any resistance.

  1. Keep infant supine with neck flexed and shoulders supported by a small roll.
  2. Shape a stylet so the tip of the endotracheal tube will curve anteriorly at 90 degrees. Be certain the tip of the stylet stays above the end of the ET tube. Alternately, freeze an ET tube in this configuration and remove stylet just prior to insertion.
  3. Maintaining the curve in the tube anterior, insert the tube carefully through the nostril until its tip is in the oropharynx.
  4. Pull the jaw forward into a sniff position with the head midline and put slight external pressure over the cricoid cartilage.
  5. Advance the tube to a suitable depth unless there is any resistance.
  6. Remove stylet and verify presence of exhaled humidity and equal breath sounds.

Intubation in Severe Cleft Defects

There are several possible modifications for ET tubes that are useful for fixation or elective intubation when there is a large cleft palate. For emergency intubations, the following modification using a standard tongue blade is usually immediately available (6). For techniques or difficult intubation alternatives, see above (7).

  1. Open infant's mouth and lay sterile tongue blade flat across maxilla, with ends extending from corners mouth. Have assistant hold in place.
  2. Follow steps for routine intubation, using tongue blade for support of laryngoscope as necessary.
  3. After intubation, fix tube to padded tongue blade.
  4. Recognize that tongue thrust on tube in absence of a normal palate may lead to extubation even without visible external lengthening of tube.

Emergency Retrograde Intubation (8)

When facial anomalies preclude other routes, retrograde intubation using a modified Seldinger technique is possible. Because the cartilaginous support of the trachea is so poor, needle puncture is far more difficult in neonates.

Equipment

  1. Venous cannula with stylet, 14 or 16 gauge
  2. Feeding catheter. Verify that the catheter will pass through the lumen of the angiocath.
  3. A 14-gauge cannula will admit a 5-French (Fr) feeding tube.
  4. A 16-gauge cannula will admit a 3.5-Fr feeding tube.
  5. Hemostat
  6. Endotracheal tube

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Technique

  1. Sedate infant if possible.
  2. Clean skin over cricothyroid area
  3. At the level of the cricothyroid, puncture skin with cannula and stylet. Angle cannula at 45 degrees from the skin and directed toward the head.
  4. Insert into lumen or trachea only until there is a give in resistance or air returns.
  5. Remove the stylet.
  6. Thread feeding tube through the lumen of the cannula until it can be retrieved from the nose or oropharynx.
  7. Bring cephalic end of feeding tube out of the nose or mouth, leaving other end well outside skin insertion.
  8. While feeding tube is in place, remove the cannula from the tracheal insertion site.
  9. Clamp the feeding tube at its tracheal insertion so it will not be pulled into the trachea farther than desired.
  10. At the upper end, slip the ET tube over the feeding tube and along its course until it has passed the proper distance into the trachea. Stabilize the ET tube.
  11. Cut the feeding tube at its tracheal insertion.
  12. While keeping the ET tube in place, pull the feeding tube through the ET tube.
  13. Secure ET tube after verifying correct intratracheal position.

References

  1. Georgeson K, Vain N.Intubation of the left main bronchus in the newborn infant: a new technique. J Pediatr. 1980;96:920.
  2. Mathew O, Thach B.Selective bronchial obstruction for treatment of bullous interstitial emphysema. J Pediatr. 1980;96:475.
  3. Weintraub Z, Oliven A, Weissman D, Sonis A.A new method for selective left main bronchus intubation in premature infants. J Pediatr Surg. 1990;25:604.
  4. Sivasubramanian K.Technique of selective intubation of the left bronchus in newborn infants. J Pediatr. 1979;94:479.
  5. Williamson R.Blind nasal intubation of an apneic neonate. Anesthesiology. 1988;69(4):633.
  6. Zawistowska J, Menzel M, Wytyczak M.Difficulties and modifications of intubation technique in infants with labial, alveolar and palatal clefts. Anaesth Resusc Intens Ther. 1973;1:211.
  7. Stool SE.Intubation techniques of the difficult airway. Pediatr Infect Dis J. 1988;7:154.
  8. Cooper CM, Murray-Wilson A.Retrograde intubation. Management of a 4.8 kg, 5 month infant. Anaesthesia. 1987; 42:1197.

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Appendix E: Chapter 50

TABLE E.1 Drugs Requiring Adjustment in Severe Renal Failure